Effectiveness of Eccentric Exercises in the Management of Chronic Achilles Tendinosis

A Peer Reviewed Publication of the College of Allied Health & Nursing at Nova Southeastern University Dedicated to allied health professional practice and education http://ijahsp.nova.edu Vol.5 No. 2 ISSN 1540-580X Effectiveness of Eccentric Exercises in the Management of Chronic Achilles Tendinosis Carla van Usen Barbara Pumberger University of South Australia Citation: van Usen, C., Pumberger, B. Effectiveness of eccentric exercises in the management of chronic Achilles tendinosis. The Internet Journal of Allied Health Sciences and Practice. April 2007, Volume 5 Number 2. Abstract Background: Chronic Achilles tendinosis is commonly seen in clinical practice however the causes are largely unknown. In the last ten years good results have been reported with a range of approaches, one of which is eccentric training. Objective: This study reports on a systematic review of the literature to determine the effectiveness of eccentric training compared with other types of interventions for chronic Achilles tendinosis. Method: A systematic review of the published research literature was conducted to examine the quantity, nature, quality and significance of literature relevant to the effectiveness of eccentric training for chronic Achilles tendinosis. Subject inclusion criteria were being at least 16 years of age, having a minimum of three months of complaints and no other underlying pathologies. Results: Seven databases were searched, and 25 studies were included. They reflected a variety of research designs and study quality. Comparison interventions included surgery, medications and passive treatment. An index combining results and quality showed that the best options for managing Achilles tendinosis were medication and eccentric exercises. Taking account of factors such as cost, safety and inconvenience, eccentric exercises are favoured over drug intervention. Conclusion: Eccentric exercises are simple to perform and provide a cost effective, safe and efficient way to treat Achilles tendinosis. They should be considered first for all patients, before invasive interventions such as surgery and drug therapy. Background Chronically painful Achilles tendons are a common feature in Western society and are often treated in physiotherapy clinics. The condition is mostly found in recreational athletes, especially runners, or in participants in sports involving running. It is estimated that 6-18% of the injuries related to running are Achilles tendon disorders. The condition can also be present in sedentary or older people; however, with unknown aetiology.1 It is important to treat individuals with this condition appropriately as early as possible, as left untreated, this condition can be debilitating and frustrating.2 The socio-economic impact of treatments should be considered, as treatment requiring time off work and invasive treatment such as surgery or injections represents a higher cost to society than noninvasive treatments that can be carried out at home. In the literature, a range of terms is used to describe painful Achilles tendons, often producing diagnostic confusion. Other diagnostic nomenclature includes achillodynia, tendinopathy, tendonitis, and tendinosis, © The Internet Journal of Allied Health Sciences and Practice, 2007 and other terms which often do not reflect the underlying pathology.3 The most widely accepted term is tendinosis, which is linked to the presence of degenerative changes in the tendon.3 Alfredson et al reported that there were no signs of inflammation (i.e. higher levels of prostaglandin E2 levels) in a chronic painful Achilles tendon, however this incurs ongoing discussion in the literature.4,5 The debate further complicates the diagnosis of painful Achilles tendons. It is commonly accepted that chronic musculoskeletal conditions are those of three months duration or longer.2 The etiology of chronic Achilles tendon problems is largely unknown, with speculation on a number of causes believed to contribute to the problem. It is agreed that it is most likely a combination of anatomical and biomechanical factors, as well as persistent overuse, resulting in repetitive micro-trauma to the tendon.1,6 Congruent with difficulties in establishing etiology and causal factors, treatment regimes are controversial. Different techniques are proposed as being effective and Effectiveness of Eccentric Exercises in the Management of Chronic Achilles Tendinosis are underpinned by variable research evidence. An approach which has become increasingly popular with physiotherapists is eccentric exercises which consist of heel drops on the injured side and the contralateral side assisting with a concentric contraction to regain the starting position. The purpose of eccentric exercises is to strengthen the muscle by lengthening muscle fibers whilst contracting against gravity. This approach was first introduced by Stanish et al and later developed and described by Alfredson et al.7,8 In light of this debate, it seems important to take a closer look at the types of management described in the literature to see how their effectiveness compares and what evidence is available for each as a viable intervention in a general clinical setting. Examples of interventions that are commonly used are medication, exercises/stretching, electrotherapy, and surgery. Since eccentric exercises have been well documented over the last decade, and good results have been consistently reported, it seems relevant to compare this approach with all other treatment approaches. The aim of this study was to investigate the evidence of effectiveness of eccentric exercise programs compared with the effectiveness of other approaches in the management of chronic Achilles tendinosis in adults. Methods Search terms: A systematic search was conducted in all available and relevant databases at the University of South Australia comprising Medline, CINAHL, SPORTDiscus, PubMed, Cochrane, AMED, and Google Scholar. The keywords used to search the databases were Achilles tendon, tendinosis, tendinopathy, achillodynia, eccentric, exercise, treatment, management, physiotherapy, and all possible variants of these terms. Selection criteria Studies were included in which subjects presented with symptoms of Achilles tendinosis, present for at least 3 months in one limb, and confirmed by a clinical diagnosis. This consisted in almost all studies of a clinical examination of the tendon and a confirmation with diagnostic ultrasound. Two studies, however, used only this clinical examination and two studies used MRI as a diagnostic tool.1,2,14,21 An intervention for the affected Achilles tendon was an essential inclusion criterion. Excluded were studies where subjects were less than 16 years of age, had symptoms existing no longer than 3 months, or were diagnosed with underlying pathologies such as rheumatoid arthritis or a previously ruptured tendon. Any outcome measure was included as there is currently no gold stan (...truncated)